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IIR 05-213 – HSR&D Study

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IIR 05-213
Sleep Specialty Consultation: Improving Management of Sleep Disorders
Jack D. Edinger PhD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: January 2007 - December 2010

BACKGROUND/RATIONALE:
Sleep disorders such as insomnia, obstructive sleep apnea (OSA), and restless legs syndrome (RLS) are widespread health problems that reduce quality of life, increase risks for medical disease, and enhance health care utilization and costs among affected individuals. A substantial portion of patients with such conditions never consult a sleep specialist. Instead they seek help in primary care, where they typically receive cursory assessment of their complaints and generic treatment (hypnotic medications) that often proves ineffective. As a consequence, many such patients are left with unresolved or progressive sleep disturbances that increase their risk for other serious medical and psychiatric disorders and/or enhance their utilization of the health care system.

OBJECTIVE(S):
This project tested a once-only sleep specialty consultation (SSC) for improving nocturnal sleep, diurnal functioning, health-related quality of life perceptions, satisfaction with medical care, and health care utilization among veterans enrolled in the Primary Care Clinics of the Durham VAMC. The SSC consisted of: (1) a comprehensive interview and history-based sleep disorder assessment with a sleep specialist; (2) sharing resultant diagnostic impressions and relevant treatment recommendations with the study patient; and (3) conveying diagnostic impressions, suggestions for additional diagnostic testing, and treatment recommendations to the patient's primary provider.

METHODS:
A total of 137 veteran outpatients with sleep complaints were enrolled in this randomized, parallel group, clinical effectiveness study. Of these, 68 were randomized to the SSC intervention and the remaining 69 were assigned to a care as usual waitlist control condition (WLC). Eligibility criteria included: sleep complaint for greater than 1 month duration; Pittsburgh Sleep Quality Index score greater than 5; mental status score greater than or equal to 24 on Folstein MMSE; no unstable medical or psychiatric disorder; and approval of primary provider. Those assigned to SSC were provided one visit with a sleep specialist wherein they underwent a thorough interview-based sleep assessment and subsequently received relevant recommendations for the management of their sleep-related complaints. In addition, these recommendations were provided to patients' respective primary care providers along with instructions for their implementation. WLC patients were not provided any contact with the sleep specialist, but were encouraged to consult their primary care providers about their sleep complaints. Provider-focused outcomes included measures of provider adherence to SSC recommendations, as well as the number of sleep-focused interventions initiated by providers of patients in both treatment arms. Patient-focused outcomes included sleep diaries, actigraphic sleep monitoring, and questionnaires to assess sleep/wake symptoms, mood, quality of life and healthcare satisfaction collected immediately before randomization and again at 5- and 10-month post-randomization time points.

FINDINGS/RESULTS:
Providers showed good adherence to SSC recommendations; adherence rates ranged from 67% for suggested referrals for nightmare-specific therapies to 95% for recommendations to conduct sleep lab evaluations. Provider-initiated sleep-focused interventions were significantly more frequent in the SSC group vs. the WLC group, including PSG referrals (p<.0001), mental health clinic referrals (p<.05), and medication for restless legs (p<.05). Patient-focused outcomes showed the SSC group had greater reductions in subjective measures (diary) of total wake time and sleep efficiency by the 10-month follow-up than did the WLC group. The SSC showed somewhat greater improvements in their PSQI total scores than did the WLC group (p < .08; ES = .26) at 10-month follow-up. Additionally, there was a notable (albeit, non-significant) trend for SSC patient to have greater daytime alertness by the final follow-up. Slightly over 56% of the SSC sample achieved normative scores on a measure of daytime sleepiness, whereas only about 43% of the WLC achieved this milestone.

IMPACT:
This study shows the benefits of a relatively brief sleep specialist intervention for VA patients with mixed sleep complaints. The intervention tested was very effective in influencing primary care providers' attention to, and proper management of, their patients' sleep complaints. In turn, patients appeared to show some modest sleep/wake benefits as well. The collaborative care intervention tested is fairly simple to implement, and hence, should be easy to disseminate throughout the VA system. Future research should focus on methods of enhancing the short-term sleep/wake outcomes for patients receiving such intervention, as well as determining the impact of such intervention on health status overall.

PUBLICATIONS:

Journal Articles

  1. Edinger JD, Grubber J, Ulmer C, Zervakis J, Olsen M. A Collaborative Paradigm for Improving Management of Sleep Disorders in Primary Care: A Randomized Clinical Trial. Sleep. 2016 Jan 1; 39(1):237-47.
  2. Olsen MK, Stechuchak KM, Edinger JD, Ulmer CS, Woolson RF. Move over LOCF: principled methods for handling missing data in sleep disorder trials. Sleep Medicine. 2012 Feb 1; 13(2):123-32.
Journal Other

  1. Edinger JD, Ulmer CS, Grubber J, Zervakis JB, Olsen MK. Effects of a One-Time Sleep Specialty Consultation on Sleep Problem Management in Primary Care. [Abstract]. Sleep. 2011 Oct 20; 34(Suppl):A337,0984.
  2. Zervakis JB, Ulmer CS, Edinger JD. Can a One-Time Sleep Specialty Consultation Enhance Providers' Attention to Sleep Problems in Primary Care? [Abstract]. Sleep. 2010 Mar 1; 33(Suppl):A365,1092.
Conference Presentations

  1. Edinger JD, Grubber J, Ulmer CS, Zervakis JB, Olsen MK. Collaborative Care Model for Improving Sleep Disorders Management in Primary Care. Presented at: World Association of Sleep Medicine International Annual Congress; 2013 Oct 2; Valencia, Spain.
  2. Edinger JD, Grubber J, Ulmer CS, Zervakis JB, Olsen MK. Effects of a one-time sleep specialty consultation on sleep problem management in primary care. Poster session presented at: Associated Professional Sleep Societies, LLC Annual Meeting; 2011 Jun 15; Minneapolis, MN.
  3. Ulmer CS, Edinger JD, Calhoun PS, Almirall D, Bosworth HB. A Multi-Component Cognitive-Behavioral Intervention for Sleep Disturbance in Veterans with PTSD: A Pilot Study. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 12; Minneapolis, MN.


DRA: Mental, Cognitive and Behavioral Disorders, Aging, Older Veterans' Health and Care, Health Systems
DRE: Treatment - Observational, Prevention, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Care Management, Chronic disease (other & unspecified), Sleep disorders
MeSH Terms: none

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